Exploring predictors and prevalence of postpartum depression among mothers: Multinational study

Background Postpartum depression (PPD) affects around 10% of women, or 1 in 7 women, after giving birth. Undiagnosed PPD was observed among 50% of mothers. PPD has an unfavorable relationship with women’s functioning, marital and personal relationships, the quality of the mother-infant connection, and the social, behavioral, and cognitive development of children. We aim to determine the frequency of PPD and explore associated determinants or predictors (demographic, obstetric, infant-related, and psychosocial factors) and coping strategies from June to August 2023 in six countries. Methods An analytical cross-sectional study included a total of 674 mothers who visited primary health care centers (PHCs) in Egypt, Yemen, Iraq, India, Ghana, and Syria. They were asked to complete self-administered assessments using the Edinburgh Postnatal Depression Scale (EPDS). The data underwent logistic regression analysis using SPSS-IBM 27 to list potential factors that could predict PPD. Results The overall frequency of PPD in the total sample was 92(13.6%). It ranged from 2.3% in Syria to 26% in Ghana. Only 42 (6.2%) were diagnosed. Multiple logistic regression analysis revealed there were significant predictors of PPD. These factors included having unhealthy baby adjusted odds ratio (aOR) of 11.685, 95% CI: 1.405–97.139, p = 0.023), having a precious baby (aOR 7.717, 95% CI: 1.822–32.689, p = 0.006), who don’t receive support (aOR 9.784, 95% CI: 5.373–17.816, p = 0.001), and those who are suffering from PPD. However, being married and comfortable discussing mental health with family relatives are significant protective factors (aOR = 0.141 (95% CI: 0.04–0.494; p = 0.002) and (aOR = 0.369, 95% CI: 0.146–0.933, p = 0.035), respectively. Conclusion The frequency of PPD among the mothers varied significantly across different countries. PPD has many protective and potential factors. We recommend further research and screenings of PPD for all mothers to promote the well-being of the mothers and create a favorable environment for the newborn and all family members. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-024-18502-0.


Introduction
Postpartum depression (PPD) is among the most prevalent mental health issues [1].The onset of depressive episodes after childbirth occurs at a pivotal point in a woman's life and can last for an extended period of 3 to 6 months; however, this varies based on several factors [2].PPD can develop at any time within the first year after childbirth and last for years [2].It refers to depressive symptoms that a mother experiences during the postpartum period, which are vastly different from "baby blues, " which many mothers experience within three to five days after the birth of their child [3].
Depressive episodes are twice as likely to occur during pregnancy compared to other times in a woman's life, and they frequently go undetected and untreated [4].According to estimates, almost 50% of mothers with PPD go undiagnosed [4].The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PPD include mood instability, loss of interest, feelings of guilt, sleep disturbances, sleep disorders, and changes in appetite [5], as well as decreased libido, crying spells, anxiety, irritability, feelings of isolation, mental liability, thoughts of hurting oneself and/or the infant, and even suicidal ideation [6].
Approximately 1 in 10 women will experience PPD after giving birth, with some studies reporting 1 in 7 women [7].Globally, the prevalence of PPD is estimated to be 17.22% (95% CI: 16.00-18.05)[4], with a prevalence of up to 15% in the previous year in eighty different countries or regions [1].This estimate is lower than the 19% prevalence rate of PPD found in studies from lowand middle-income countries and higher than the 13% prevalence rate (95% CI: 12.3-13.4%)stated in a different meta-analysis of data from high-income countries [8].
The occurrence of postpartum depression is influenced by various factors, including social aspects like marital status, education level, lack of social support, violence, and financial difficulties, as well as other factors such as maternal age (particularly among younger women), obstetric stressors, parity, and unplanned pregnancy [4].When a mother experiences depression, she may face challenges in forming a satisfying bond with her child, which can negatively affect both her partner and the emotional and cognitive development of infants and adolescents [4].As a result, adverse effects may be observed in children during their toddlerhood, preschool years, and beyond [9].
Around one in seven women can develop PPD [7].While women experiencing baby blues tend to recover quickly, PPD tends to last longer and severely affects women's ability to return to normal function.PPD affects the mother and her relationship with the infant [7].The prevalence of postpartum depression varies depending on the assessment method, timing of assessment, and cultural disparities among countries [7].To address these aspects, we conducted a cross-sectional study focusing on mothers who gave birth within the previous 18 months.Objectives: to determine the frequency of PPD and explore associated determinants or predictors, including demographic, obstetric, infant-related, and psychosocial factors, and coping strategies from June to August 2023 in six countries.

Study design and participants
This is an analytical cross-sectional design and involved 674 mothers during the childbearing period (CBP) from six countries, based on the authors working settings, namely Egypt, Syria, Yemen, Ghana, India, and Iraq.It was conducted from June to August 2023.It involved all mothers who gave birth within the previous 18 months, citizens of one of the targeted countries, and those older than 18 years and less than 40 years.Women who visited for a routine postpartum follow-up visit and immunization of their newborns were surveyed.
Multiple pregnancies, illiteracy, or anyone deemed unfit to participate in accordance with healthcare authorities, mothers who couldn't access or use the Internet, mothers who couldn't read or speak Arabic or English and couldn't deal with the online platform or smart devices, mothers whose babies were diagnosed with serious health problems, were stillborn, or experienced intrauterine fetal death, and participants with complicated medical, mental, or psychological disorders that interfered with completing the questionnaire were all exclusion criteria.There were no incentives offered to encourage participation.

Sample size and techniques
The sample size was estimated according to the following equation: n = Z 2 P (1-P)/d 2 .This calculation was based on the results of a systematic review and meta-analysis in 2020 of 17% as the worldwide prevalence of PPD and 12% as the worldwide incidence of PPD, as well as a 5% precision percentage, 80% power of the study, a 95% confidence level, and an 80% response rate [11].The total calculated sample size is 675.The sample was diverse in terms of nationality, with the majority being Egyptian (16.3%), followed by Yemeni (24.3%) and Indian (19.1%), based on many factors discussed in the limitation section.
The sampling process for recruiting mothers utilized a multistage approach.Two governorates were randomly selected from each country.Moreover, we selected one rural and one urban area from each governorate.Through random selection, participants were chosen for the study.Popular and officially recognized online platforms, including websites and social media platforms such as Facebook, Twitter, WhatsApp groups, and registered emails across various health centers, were utilized for reaching out to participants.Furthermore, a community-based sample was obtained from different public locations, including well-baby clinics, PHCs, and family planning units.
Mothers completed the questionnaire using either tablets or cellphones provided by the data collectors or by scanning the QR code.All questions were mandatory to prevent incomplete forms.Once they provided their informed consent, they received the questionnaire, which they completed and submitted.To enhance the response rate, reminder messages and follow-up communications were employed until the desired sample size was achieved or until the end of August.To avoid seasonal affective disorders, the meteorological autumn season began on the 1st day of September, which may be associated with Autum depressive symptoms that may confound or affect our results.

Questionnaire development and structure
The questionnaire was developed and adapted based on data obtained from previous studies [7][8][9][10][11][12].Initially, it was created in English and subsequently translated into Arabic.To ensure accuracy, a bilingual panel consisting of two healthcare experts and an externally qualified medical translator translated the English version into Arabic.Additionally, two English-speaking translators performed a back translation, and the original panel was consulted if any concerns arose.

Questionnaire validation
To collect the data, an online, self-administered questionnaire was utilized, designed in Arabic with a wellstructured format.We conducted an assessment of the questionnaire's reliability and validity to ensure a consistent interpretation of the questions.The questionnaire underwent validation by psychiatrists, obstetricians, and gynecologists.Furthermore, in a pilot study involving 20 women of CBA, the questionnaire's clarity and comprehensibility were evaluated.It is important to note that the findings from the pilot study were not included in our main study.
The participants were asked to rate the questionnaire's organization, clarity, and length, as well as provide a general opinion.Following that, certain questions were revised in light of their input.To check for reliability and reproducibility, the questionnaire was tested again on the same people one week later.The final data analysis will not include the data collected during the pilot test.We calculated a Cronbach's alpha of 0.76 for the questionnaire.

The structure of the questionnaire
After giving their permission to take part in the study.The questionnaire consisted of the following sections: • Study information and electronic solicitation of informed consent.

Statistical analysis
The collected data was computerized and statistically analyzed using the SPSS program (Statistical Package for Social Science), version 27.The data was tested for normal distribution using the Shapiro-Walk test.Qualitative data was represented as frequencies and relative percentages.Quantitative data was expressed as mean ± SD (standard deviation) if it was normally distributed; otherwise, median and interquartile range (IQR) were used.The Mann-Whitney test (MW) was used to calculate the difference between quantitative variables in two groups for non-parametric variables.Correlation analysis (using Spearman's method) was used to assess the relationship between two nonparametric quantitative variables.All results were considered statistically significant when the significant probability was < 0.05.The chi-square test (χ 2 ) and Fisher exact were used to calculate the difference between qualitative variables.

Results
The frequency of PPD among mothers (Fig. 1) The frequency of PPD in the total sample using the Edinburgh 10-question scale was 13.5% (Table S1) and 92 (13.6% PPD is significant (p < 0.05).Higher among single or widowed women 9 (56.3%) and mothers who had both medical, mental, or psychological problems 2 (66.7%), with ex-cigarette smoking 5 (35.7%) (p = 0.033), alcohol consumption (p = 0.022) and mothers were charged for the health care services for themselves 59 (11.9%).
There was a significant (P < 0.05) association observed between PPD, which was significantly higher among mothers on contraceptive methods, and those who had 1-2 live births (76.1%) and mothers who had interpregnancy space for less than 2 years.86 (93.5%), and those who had a history of dead children.Moreover, among those who had postnatal problems (27.2%).

The psychosocial characteristics and their association with PPD (Table 3)
Regarding the psychological and social characteristics of the mothers, the majority of mothers were unaware of the symptoms of PPD (75%), and only 236 (35.3%) experienced cultural stigma or judgment about PPD in the community.About 41 (6.1%) were diagnosed with PPD during the previous pregnancy, and only 42 (6.2%)were diagnosed and on medications.
A p-value of less than 0.001 demonstrates a highly statistically significant association with the presence of PPD.Mothers with PPD were significantly more likely to have a history of or be currently diagnosed with PPD, as well as financial and marital problems.Experienced cultural stigma or judgment about PPD and received more support.

Coping strategies and causes for not receiving the treatment and reaction to PPD (Table 3; Fig. 2)
Around half of the mothers didn't feel comfortable discussing mental health: 292 (43.3%) with a physician, 307 (45.5%) with a husband, 326 (48.4%) with family, and 472 (70.0%) with the community.Moreover, mothers with PPD felt significantly more comfortable discussing mental health in descending order: 46 (50.0%) with a physician, 41 (44.6%) with a husband, and 39 (42.3%) with a family (Table 3).
There were different causes for not receiving the treatment and reactions to PPD, in descending order: 65.7% social norms, 60.5% cultural or traditional beliefs, 56.5% personal barriers, 48.5% geographical or regional disparities in mental health resources, 47.4% language or communication barriers, and 39.7% financial constraints.

Significant demographic predictors of PPD
Marital Status (Married or Single): The adjusted odds ratio (aOR) among PPD mothers who were married in comparison to their single counterparts was 0.141 (95% CI: 0.04-0.494;p-value = 0.002).#p < 0.05 there was a statistically significant difference Fig. 2 Causes for not receiving the treatment and reaction to PPD Nationality: For PPD Mothers of Yemeni nationality compared to those with Egyptian nationality, the aOR was 0.318 (95% CI: 0.123-0.821,p = 0.018).Similarly, for Syrian nationality in comparison to Egyptian nationality, the aOR was 0.111 (95% CI: 0.0139-0.887,p = 0.038), and for Iraqi nationality compared to Egyptian nationality, the aOR was 0.241 (95% CI: 0.0920-0.633,p = 0.004).

Current Pregnancy Status (Precious Baby-Planned):
The aOR for the occurrence of PPD among women with a "precious baby" relative to those with a "planned" pregnancy was 7.717 (95% CI: 1.822-32.689,p = 0.006).
Healthy Baby (No-Yes): The aOR for the occurrence of PPD among women with unhealthy babies in comparison to those with healthy ones is 11.685 (95% CI: 1.405-97.139,p = 0.023).

Significant psychological and social predictors of PPD
Receiving support or treatment for PPD (No-Yes): The aOR among PPD mothers who were not receiving support or treatment relative to those receiving support or treatment was 9.784 (95% CI: 5.373-17.816,p = 0.001).
Awareness of symptoms and risk factors (No-Yes): The aOR among PPD mothers who lack awareness of symptoms and risk factors relative to those with awareness was 2.902 (95% CI: 1.633-5.154,p = 0.001).
Experienced cultural stigma or judgement about PPD in the community (No-Yes): The aOR among PPD mothers who had experienced cultural stigma or judgment in the community relative to those who have not was 4.406 (95% CI: 2.394-8.110,p < 0.001).
Suffering from any disease or mental or psychiatric disorder: For "Now I am suffering-not at all, " the aOR among PPD mothers was 12.871 (95% CI: 3.063-54.073,p = 0.001).Similarly, for "Had a past history but was treated-not at all, " the adjusted odds ratio was 16.6 (95% CI: 2.528-108.965,p = 0.003), and for "Had a family history-not at all, " the adjusted odds ratio was 3.551 (95% CI: 1.012-12.453,p = 0.048).

Significant coping predictors of PPD comfort: discussing mental health with family (maybe yes)
The aOR among PPD mothers who were maybe more comfortable discussing mental health with family relatives was 0.369 (95% CI: 0.146-0.933,p = 0.035).

Discussion
PDD is a debilitating mental disorder that has many potential and protective risk factors that should be considered to promote the mental and psychological well-being of the mothers and to create a favorable environment for the newborn and all family members.This multinational cross-sectional survey was conducted in six different countries to determine the frequency of PDD using EPDS and to explore its predictors.It was found that PPD was a prevalent problem that varied across different nations.
Lower frequencies were than those reported; PPD is a predominant problem in Asia, e.g., in Pakistan, the three-month period after childbirth, ranging from 28.8% in 2003 to 36% in 2006 to 94% in 2007, while after 12 months after childbirth, it was 62% in 2021 [23][24].While in 2022 Afghanistan 45% after their first labour [25] in Canada (2015) was 40% [26], in India, the systematic review in 2022 was 22% of Primipara [27], in Malaysia (2006) was 22.8% [28], in India (2019) was 21.5% [29], in the Tigray zone in Ethiopia (2017) was 19% [30], varied in Iran between 20.3% and 35% [31][32], and in China was 499 (27.37%) out of 1823 [33].A possible explanation might be the differences in the study setting and the type of design utilized.Other differences should be considered, like different populations with different socioeconomic characteristics and the variation in the timing of post-partum follow-up.It is vital to consider the role of culture, the impact of patients' beliefs, and the cultural support for receiving help for PPD. 1 and 4)

Demographic and health-related associations, or predictors of PPD (Tables
Regarding age, our study found no significant difference between PPD and non-PPD mothers with regard to age.In agreement with our study [12,34,35], other studies [36][37][38] found an inverse association between women's age and PPD, with an increased risk of PPD (increases EPDS scores) at a younger age significantly, as teenage mothers, being primiparous, encounter difficulty during the postpartum period due to their inability to cope with financial and emotional difficulties, as well as the challenge of motherhood.Cultural factors and social perspectives of young mothers in different countries could be a reason for this difference.[38][39] and Abdollahi et al. [36] reported that older mothers were a protective factor for PPD (OR = 0.88, 95% CI: 0.84-0.92]. Regarding marital status, after controlling for other variables, married mothers exhibited a significantly diminished likelihood of experiencing PPD in comparison to single women (0.141; 95% CI: 0.04-0.494;p = 0.002).Also, Gebregziabher et al. [19] reported that there were statistically significant differences in proportions between mothers' PPD and marital status.
Regarding the mother's education, in agreement with our study, Ahmed et al. [34] showed that there was no statistically significant difference between PPD and a mother's education.While Agarwala et al. [29] showed that a higher level of mother's education.increases the risk of PPD, Gebregziabher et al. [19] showed that the housewives were 0.24 times less likely to develop PPD as compared to the employed mothers (aOR = 0.24, 95% CI: 0.06-0.97;p = 0.046); those mothers who perceived their socioeconomic status (SES) as low were 13 times more likely to develop PPD as compared to the mothers who had good SES (aOR = 13.33,95% CI: 2.66-66.78;p = 0.002).
Regarding the SES or monthly income, while other studies [18,40] found that there was a statistically significant association between PPD mothers and different domains of SES, 34% of depressed women were found to live under low SES conditions in comparison to only 15.4% who were found to live in high SES and experienced PPD.In disagreement with our study, Hairol et al. [12] demonstrated that the incidence of PPD was significantly p = 0.01 higher for participants from the low-income group (27.27%) who were 2.58 times more likely to have PDD symptoms (OR: 2.58, 95% CI: 1.23-5.19;p = 0.01 compared to those from the middle-and high-income groups (8.33%), and low household income (OR = 3.57 [95% CI: 1.49-8.5]increased the odds of PPD [41].Adeyemo et al. (2020),and Al Nasr et al. (2020) revealed that there was no significant difference between the occurrence of PPD and socio-demographic characteristics.This difference may be due to a different sample size and ethnicity [42,43].In agreement with our findings, Abdollahi et al. [36] demonstrated that after multiple logistic regression analyses, there were increased odds of PPD with a lower state of general health (OR = 1.08 [95% CI: 1.06-1.11]),gestational diabetes (OR = 2.93 [95% CI = 1.46-5.88]),and low household income (OR = 3.57 [95% CI: 1.49-8.5]).The odds of PPD decreased.
Regarding access to health care, in agreement with studies conducted at Gondar University Hospital, Ethiopia [18], North Carolina, Colorado [21], Khartoum, Sudan [44], Asaye et al. [45], the current study found that participants who did not have free access to the healthcare system were riskier for the development of PPD. the study results may be affected by the care given during the antenatal care (ANC) visits.This can be explained by the fact that PPD was four times higher than that of mothers who did not have ANC, where counseling and anticipatory guidance care are given that build maternal self-esteem and resiliency, along with knowledge about normal and problematic complications to discuss at care visits and their right to mental and physical wellness, including access to care.The increased access to care (including postpartum visits) will increase the diagnosis of PPD and provide guidance, reassurance, and appropriate referrals.Healthcare professionals have the ability to both educate and empower mothers as they care for their babies, their families, and themselves [46].
Regarding nationality, for PPD mothers of Yemeni nationality compared to those of Egyptian nationality, the aOR is 0.318 (95% CI: 0.123-0.821,p = 0.018).Similarly, for Syrian nationality in comparison to Egyptian nationality, the aOR is 0.111 (95% CI: 0.0139-0.887,p = 0.038), and for Iraqi nationality compared to Egyptian nationality, the aOR is 0.241 (95% CI: 0.0920-0.633,p = 0.004).These findings indicated that, while accounting for other covariates, individuals from the aforementioned nationalities were less predisposed to experiencing PPD than their Egyptian counterparts.These findings can be explained by the fact that, in Egypt, the younger age of marriage, especially in rural areas, poor mental health services, being illiterate, dropping out of school early, unemployment, and the stigma of psychiatric illnesses are cultural factors that hinder the diagnosis and treatment of PPD [40]. 2 and 4)

Obstetric, current pregnancy, and infant-related characteristics and their association or predictors of PPD (Tables
In the present study, the number of dead children was significantly associated with PPD.This report was supported by studies conducted with Gujarati postpartum women [41] and rural southern Ethiopia [43].This might be because mothers who have dead children pose different psychosocial problems and might regret it for fear of complications developing during their pregnancy.Agarwala et al. [29] found that a history of previous abortions and having more than two children increased the risk of developing PPD due to a greater psychological burden.The inconsistencies in the findings of these studies indicate that the occurrence of postpartum depression is not solely determined by the number of childbirths. In obstetric and current pregnancy, there was no significant difference regarding the baby's age, number of miscarriages, type of last delivery, premature labour, healthy baby, baby admitted to the neonatal intensive care unit (NICU), or feeding difficulties.In agreement with Al Nasr et al. [42], inconsistent with Asaye et al. [45], they showed that concerning multivariable logistic regression analysis, abortion history, birth weight, and gestational age were significant associated factors of postpartum depression at a value of p < 0.05.
However, a close association was noted between the mode of delivery and the presence of PPD in mothers, with p = 0.107.There is a high tendency towards depression seen in mothers who have delivered more than three times (44%).In disagreement with what was reported by Adeyemo et al. [41], having more than five children (p = 0.027), cesarean section delivery (p = 0.002), and mothers' poor state of health since delivery (p < 0.001) are associated with an increase in the risk of PPD [47].An increased risk of cesarean section as a mode of delivery was observed (OR = 1.958, p = 0.049) in a study by Al Nasr et al. [42].
We reported breastfeeding mothers had a lower, nonsignificant frequency of PPD compared to non-breastfeeding mothers (36.6% vs. 45%).In agreement with Ahmed et al. [34], they showed that with respect to breastfeeding and possible PPD, about 67.3% of women who depend on breastfeeding reported no PPD, while 32.7%only had PP.Inconsistency with Adeyemo et al. [41], who reported that unexclusive breastfeeding (p = 0.003) was associated with PPD, while Shao et al. [40] reported that mothers who were exclusively formula feeding had a higher prevalence of PPD.
Regarding postnatal problems, our results revealed that postnatal problems display a significant association with PPD.In line with our results, Agarwala et al. [29] and Gebregziabher et al. [19] showed that mothers who experienced complications during childbirth, those who became ill after delivery, and those whose babies were unhealthy had a statistically significant higher proportion of PPD.
Hormone-related contraception methods were found to have a statistically significant association with PPD, consistent with the literature [46]; this can be explained by the hormones and neurotransmitters as biological factors that play significant roles in the onset of PPD.Estrogen hormones act as regulators of transcription from brain neurotransmitters and modulate the action of serotonin receptors.This hormone stimulates neurogenesis, the process of generating new neurons in the brain, and promotes the synthesis of neurotransmitters.In the hypothalamus, estrogen modulates neurotransmitters and governs sleep and temperature regulation.Variations in the levels of this hormone or its absence are linked to depression [19].

The psychosocial characteristics and their association with PPD
Mothers with a family history of mental illness were significantly associated with PPD.This finding was in accordance with studies conducted in Istanbul, Turkey [47], and Bahrain [48].Other studies also showed that women with PPD were most likely to have psychological symptoms during pregnancy [43][44][45][46][47][48][49].A meta-analysis of 24,000 mothers concluded that having depression and anxiety during pregnancy and a previous history of psychiatric illness or a history of depression are strong risk factors for developing PPD [50][51][52].Asaye et al. [45], mothers whose relatives had mental illness history were (aOR = 1.20, 95% CI: 1.09, 3.05 0) be depressed than those whose relatives did not have mental illness history.
This can be attributed to the links between genetic predisposition and mood disorders, considering both nature and nurture are important to address PDD.PPD may be seen as a "normal" condition for those who are acquainted with relatives with mood disorders, especially during the CBP.A family history of mental illness can be easily elicited in the ANC first visit history and requires special attention during the postnatal period.There are various risk factors for PPD, including stressful life events, low social support, the infant's gender preference, and low income [53].
Concerning familial support and possible PPD, a statistically significant association was found between them.We reported that mothers who did not have social support (a partner or the father of the baby) had higher odds (aOR = 5.8, 95% CI: 1.33-25.29;p = 0.019) of experiencing PPD.Furthermore, Al Nasr et al. [42] revealed a significant association between the PPD and an unsupportive spouse (P value = 0.023).while it was noted that 66.5% of women who received good familial support after giving birth had no depression, compared to 33.5% who only suffered from possible PPD [40]].Also, Adeyemo et al. [41] showed that some psychosocial factors were significantly associated with having PPD: having an unsupportive partner (p < 0.001), experiencing intimate partner violence (p < 0.001), and not getting help in taking care of their baby (p < 0.001).Al Nasr et al. (2020) revealed that the predictor of PPD was an unsupportive spouse (OR = 4.53, P = 0.049) [48].
Regarding the perceived stigma, in agreement with our study, Bina (2020) found that shame, stigma, the fear of being labeled mentally ill, and language and communication barriers were significant factors in women's decisions to seek treatment or accept help [53].Other mothers were hesitant about mental health services [54].It is noteworthy that some PPD mothers refused to seek treatment due to perceived insufficient time and the inconvenience of attending appointments [55].
PPD was significantly higher among mothers with financial problems or problems with their husbands.This came in agreement with Ahmed et al. [34], who showed that, regarding stressful conditions and PPD, there was a statistically significant association with a higher percentage of PPD among mothers who had a history of stressful conditions (59.3%), compared to those with no history of stressful conditions (40.7%).Furthermore, Al Nasr et al. (2020) revealed that stressful life events contributed significantly (P value = 0.003) to the development of PPD in the sample population.Al Nasr et al. stressful life events (OR = 2.677, p = 0.005) [42].

Coping strategies: causes of fearing and not seeking
Feeling at ease discussing mental health topics with one's husband, family, community, and physician and experiencing cultural stigma or judgment regarding PPD within the community was significantly associated with the presence of PPD.In the current study, there were different reasons for not receiving the treatment, including cultural or traditional beliefs, language or communication barriers, social norms, and geographical or regional disparities in mental health resources.Haque and Malebranche [56] portrayed culture and the various conceptualizations of the maternal role as barriers to women seeking help and treatment.
In the present study, marital status, nationality, current pregnancy status, healthy baby, postnatal problems, receiving support or treatment for PPD, having awareness of symptoms and risk factors of PPD, suffering from any disease or mental or psychiatric disorder, comfort discussing mental health with family, and experiencing cultural stigma or judgment about PPD in the community were the significant predictors of PPD.In agreement with Ahmed et al. [34], the final logistic regression model contained seven predictors for PPD symptoms: SES, history of depression, history of PPD, history of stressful conditions, familial support, unwanted pregnancy, and male preference.PPD has been recognized as a public health problem and may cause negative consequences for infants.It is estimated that 20 to 40% of women living in low-income countries experience depression during pregnancy or the postpartum period.The prevalence of PPD shows a wide variation, affecting 8-50% of postnatal mothers across countries [19].

Strengths and limitations
Strengths of our study include its multinational scope, which involved participants from six different countries, enhancing the generalizability of the findings.The study also boasted a large sample size of 674 participants, increasing the statistical power and reliability of the results.Standardized measures, such as the Edinburgh Postnatal Depression Scale (EPDS), were used for assessing postpartum depression, ensuring consistency and comparability across diverse settings.Additionally, the study explored a comprehensive range of predictors and associated factors of postpartum depression, including demographic, obstetric, health-related, and psychosocial characteristics.Rigorous analysis techniques, including multiple logistic regression analyses, were employed to identify significant predictors of postpartum depression, controlling for potential confounders and providing robust statistical evidence.
However, the study has several limitations that should be considered.Firstly, its cross-sectional design limits causal inference, as it does not allow for the determination of temporal relationships between variables.Secondly, the reliance on self-reported data, including information on postpartum depression symptoms and associated factors, may be subject to recall bias and social desirability bias.Thirdly, the use of convenience sampling methods may introduce selection bias and limit the generalizability of the findings to a broader population.Lastly, cultural differences in the perception and reporting of postpartum depression symptoms among participants from different countries could influence the results.
Moreover, the variation in sample size and response rates among countries can be attributed to two main variables.(1) The methodology showed that the sample size was determined by considering several parameters, such as allocating proportionately to the mothers who gave birth and fulfilling the selection criteria during the data collection period served by each health center.(2) The political turmoil in Syria affects how often and how well people can use the Internet, especially because the data was gathered using an online survey link, leading to a relatively low number of responses from those areas.(3) Language barrier in Ghana: as we used the Arabic and English-validated versions of the EPDS, Ghana is a multilingual country with approximately eighty languages spoken.Although English is considered an official language, the primarily spoken languages in the southern region are Akan, specifically the Akuapem Twi, Asante Twi, and Fante dialects.In the northern region, primarily spoken are the Mole-Dagbani ethnic languages, Dagaare and Dagbanli.Moreover, there are around seventy ethnic groups, each with its own unique language [57].(4) At the end of the data collection period, to avoid seasonal affective disorders, the meteorological autumn season began on the 1st day of September, which may be associated with autumm depressive symptoms that may confound or affect our results.Furthermore, the sampling methods were not universal across all Arabic countries, potentially constraining the generalizability of our findings.

Conclusion
Around 14% of the studied mothers had PPD, and the frequency varies across different countries and half of them do not know.Our study identified significant associations and predictors of postpartum depression (PPD) among mothers.Marital status was significantly associated with PPD, with married mothers having lower odds of experiencing PPD compared to single mothers.Nationality also emerged as a significant predictor, with Yemeni, Syrian, and Iraqi mothers showing lower odds of PPD compared to Egyptian mothers.Significant obstetric, current pregnancy, and infant-related predictors included the pregnancy status, the health status of the baby, and the presence of postnatal problems.Among psychological and social predictors, receiving support or treatment for PPD, awareness of symptoms and risk factors, experiencing cultural stigma or judgment about PPD, and suffering from any disease or mental disorder were significantly associated with PPD.Additionally, mothers who were maybe more comfortable discussing mental health with family relatives had lower odds of experiencing PPD.These findings underscore the importance of considering various demographic, obstetric, psychosocial, and coping factors in the identification and management of PPD among mothers.Targeted interventions addressing these predictors could potentially mitigate the risk of PPD and improve maternal mental health outcomes.

Table 1
Demographic and health-related characteristics, and their association with PPD #p < 0.05 there was a statistically significant difference

Table 2
Obstetric, current pregnancy, and infant-related characteristics, and their association with PPD #p < 0.05 there was a statistically significant difference

Table 3
Psycho and social characteristics and their association with PPD

Table 4
Significant predictors of PPD.
• The antenatal programme should incorporate health education programmes about the symptoms of PPD.Health education programs about the symptoms of PPD should be included in the antenatal program.• Mass media awareness campaigns have a vital role in raising public awareness about PPD-related issues.Mass media.• The ANC first visit history should elicit a family history of mental illness, enabling early detection of risky mothers.Family history of mental illness can be easily elicited in the ANC first visit history.• For effective management of PPD, effective support (from husband, friends, and family) is an essential component.For effective management of PPD effectiveness of support.• The maternal (antenatal, natal, and postnatal) services should be provided for free and of high quality The maternal (antenatal, natal, postnatal) services should be provided free and of high quality.• It should be stressed that although numerous studies have been carried out on PPD, further investigation needs to be conducted on the global prevalence and incidence of depressive symptoms in pregnant women and related risk factors, especially in other populations.